Care Transition for Heart Failure Patients

Care Transition for Heart Failure Patients

Care Transition for Heart Failure Patients 150 150 Peter

Care Transition for Heart Failure Patients

Describe a clinical problem in your practice setting and explain why it is a problem warranting a change to impact patient and or organizational outcomes. *The essay should be at least 500 words and professional, not personal. While you may not currently function in a direct care role, please be sure your problem can be tied to patient outcomes. Please use nursing citations and references to support your essay. Essays should be written according to APA Style 7th Edition and free from spelling and grammatical errors.
Subject: Improving Transitions of Care for Heart Failure patient in the outpatient clinic.

Sample Paper

Care Transition for Heart Failure Patients

Care transitions are usually a delicate experience for most patients. At the current workplace, heart failure patients have often reported breaks in care during the hospital-to-home care transition. They state that there is usually an adjustment period, usually lasting a few days to more than a week, where they do not receive adequate care to meet their long-term discharge goals, such as maintaining cardiac output for their lifestyle. Thus, they delay or fail to meet their optimum activity/functionality levels. Hence, caregivers must understand this concern and implement mitigations to eliminate the transition care break, thereby enhancing recovery.

Problem Description

Care breaks during the transition occur when there is no clear training and communication on a care plan for the patient. In most cases, the nurses release the patient to a family member who resolves to provide the necessary care. However, inadequate preparation often leads to the incoming caregiver failing to address all of the patient’s needs (Ghorbanzadeh et al., 2021). They also usually do not know what to do if an unexpected adverse event occurs. Consequently, the lack of sufficient preparation creates the break.

The break in care also occurs since the facility lacks an elaborate follow-up program. Caregivers rarely follow up on patients after their discharge, and when they do, it is usually out of the connection they have established with the patient or their family. Thus, there is no standard follow-up protocol, which leaves the new caregivers without professional support to provide optimal care to the patients.


The break in care standards during transition is a significant problem for multiple reasons. First, it impacts the patients’ long and short-term function performance and activity levels. When heart failure patients do not receive optimal care, their cardiac output will not improve, and they cannot attain their expected activity levels (Belleza, 2021). This problem is usually common among middle-aged patients. Most of them crave to return to normalcy, but the care break slows down the process. The delayed recovery causes poor patient satisfaction, ruining the public’s perception of the facility’s quality of care.

Next, the break in care could cause readmissions. Heart failure has one of the highest readmission rates (25% within a month and 50% within six months) (Khan et al., 2021). The short span lasting about a week where the patient does not receive the expected care due to the transition contributes to this trend. Readmissions occur because of a recurrence of the initial problem (in this case, heart failure) or the development of a complication (Ba et al., 2020). Either way, readmissions are costly to both patients and the healthcare system. Readmitted patients tend to have slower recovery rates, resulting in subpar quality of life. Thus, improving the transition process to eliminate the break would cause a significant decline in the readmission rates.

Finally, care breaks can lead to medication/care errors. The new caregivers may lack sufficient knowledge of medication administration. The lack of follow-up or a dedicated communication platform means that the caregiver does not have someone they can consult with whenever they doubt what medicines or care to provide (Ghorbanzadeh et al., 2021). Therefore, the care break exposes the patient to a heightened risk of receiving the wrong medication, which could be detrimental to their health.


During the care transition process, the breaks in care for heart failure patients hampers their overall well-being. The facility’s lack of an elaborate training program, follow-up protocol, and communication channel means that the patients receive suboptimal care. Hence, there is the need to create a nursing intervention to address this issue and enhance patient recovery, reduce readmissions, and eliminate medication/care errors.



Ba, H. M., Son, Y. Y., Lee, K., & Kim, B. H. (2020). Transitional Care Interventions for Patients with Heart Failure: An Integrative Review. International Journal of Environmental Research and Public Health,17(8), 2925.

Belleza, M. (2021, Apr. 22). Heart Failure.

Ghorbanzadeh, K., Ebadi, A., Hosseini, M., Madah, S., & Khankeh, H. (2021). Challenges of the patient transition process from the intensive care unit: a qualitative study. Acute and critical care, 36(2), 133–142.

Khan, M. S., Sreenivasan, J., Lateef, N., Abougergi, M. S., Greene, J. S., Ahmad, T., Anker, S. D., Fonarow, G. C., & Butler, J. (2021). Trends in 30- and 90-Day Readmission Rates for Heart Failure. Circulation: Heart Failure, 14(4).